Sunday, August 30, 2009

Note: All details, including names, ages, and specific descriptions of conversations with staff or patients have been considerably changed. Sorry, I know that reality blogging is more fun than fake medical encounters. Additionally, the discussion exclusively concerns people with relatively mild or well-controlled schizophrenic symptoms, with whom I can easily engage in conversation.

When the psychiatry resident asked for an update on Tracy, I glibly responded, "Still very delusional. Thinks the CIA is after her."

"She's not delusional!" the doctor corrected. "The CIA or the FBI or whatever agency really is after her. Tracy used to threaten killing former President Bush numerous times. During her last hospitalization, I had to argue with the authorities for hours, to convince them that she's safe for discharge." Thus, my near-designation on my patient's record as possessing this delusion, or a "fixed, false belief," that is not "widely held within the context of the individual's cultural or religious group" was in error. Tracy's paranoia was based on truth.

The interesting part, however, of working with schizophrenic patients is generally not figuring out what is false; Patients have spoken of receiving commands from their televisions to overthrow the "vitamin pill industry," and of obtaining classified information that their true parents are Liza Minnelli and Bobby Fisher. Many patients insist that a doctor or nurse can gain remote access to the contents of their brains, via some transhumanistic, genetic link-protocol of sorts. False belief, check.

Determining what falls under cultural norms can be a bit trickier. One patient, David, believes that he and fellow schizophrenics have powers in the "sixth dimension," on an "etherical, astral, plane," a belief that I'd brand as delusional, if I 1) Knew what it meant, curvilinear coordinates not being my forte and 2) The International Headquarters of the Theosophy Society weren't right in my hometown, flagging this as a possible local cultural or religious belief.

The main challenge in assessing delusions, however, lies mainly in determining which are considered "fixed," or intransigent to reason and the passage of time. A binary "yes" or "no" to describe the "fixedness" of a belief is inadequate. Many patients come to the hospital voluntarily, desperate to rid themselves of fearsome beliefs or voices that they know, at least in part, aren't true. Thus, they demand anti-psychotics that deny the pleasure of dopamine, and beg for mood-stabilizing drugs that inhibit norepinephrine-fueled arousal. And those are just some of the intended effects. Side effects include dystonia, neuroepileptic malignant syndrome, the frog-tongued gestures of tardive dyskinesia, and the rabbit-mouthed oscillations of EPS. Patients are often desperate to "unlearn" their beliefs, and hope to foster distrust of the voices in their head, which so distrust everyone around them.

Tom, one of my fellow medical students, asks patients an interesting question: "What do you think is the percent probability that your belief is true, and what is the percent probability that it isn't true?" Lillian, who's convinced that President Obama promised her $1 million, so long as she refrains from eating, (the Cult of the Presidency is the only thing both alive and well in the psych ward) said "About 5% of me thinks it's true, and 95% of me thinks it's not true." Five percent is not terribly much. I'm sure there are plenty of beliefs I maintain with a similar level of certainty that would confer me with at least an Axis II diagnosis, if someone could scan my brain for the latest Bayesian updates. Which leads me to wonder if percentages and predictions can adequately capture the credos that serve as the foundation for diagnosing paranoid schizophrenia.

For those of us with homo economicus pretensions, such stated probabilities may even persuade us that schizophrenic biases are simply standard deviants from very irrational mean population thought content. Indeed, critics of psychiatry often insist that people are deemed psychotic, simply because their delusions don't conform to what all the cool kids are fabricating this season. In this view, once norms change (like they did when the medical professions stopped labeling homosexuality as a disease), many schizophrenics will be considered as peers among the unhinged masses, with all our opioidic (agonistic and antagonistic both), nonsensical beliefs unleashed.

Perhaps we can focus on a more qualitative approach to evaluating "fixedness." After all, numbers don't seem to work with a patient named Mark, who contemplates (at least after he's taken his meds) of the instructions he "receives" from the devil via rap songs on the radio, "they're sometimes real...I don't know... it's so hard to separate in my head." Perhaps, we can ask an Isaac Levi-inspired series of questions, checking off what David considers "serious possibilities," out of a "potential corpora of knowledge and evidence." I can ask David, "Do you think that it's physically possible for you to hear the devil speaking to you, and only you, from the radio? Logically possible? Technologically possible? Psychologically possible?

Defenders of psychiatric designations counter their critics by noting that virtually every DSM-IV diagnosis, including schizophrenia, must involve significant impairment in occupational or social functioning. Apparently, in 2003, 20% of Americans affirmed to pollsters that an HIV vaccine already exists, but is being kept a secret. And yet, I don't see many people staging the proper revolt that such a conspiracy, if actually true, would merit. Aberrant thought content alone is not the rate-limiting-step to being diagnosed as schizophrenic. Many people have negative thoughts about the vitamin pill industry, but only Sally (who has Schizoaffective Disorder, Bipolar Type) embraced her mission by roaming in the streets, "recruiting" fellow revolutionaries (i.e. passing cars), and propelling Los Angelenos into traffic-induced hysterics.

So for paranoid schizophrenics who maintain only 5% certainty about their delusions, perhaps they simply act upon this glimmer of confidence more often than others, like the "Deal or No Deal" folks who, knowing basic math, still reject the banker's actuarially outlandish offer, because, what if the million is in my box? According to polls, many Americans claim that our current president is a foreigner, and is thus ineligible for his elected position, according to our country's most sacred national document. Then we go off to do our laundry and water our lawns. However, there are always those few that can't eat, sleep, or tweet, while harboring such persistent ideations of conspiracy.

A behaviorist might say that, Bayesian self-reports not-withstanding, patients' actions exclusively measure their convictions. Skinnerians will believe our stated fidelity to untruth when they see it! All the rest perhaps just falls under the purview of "symbolic belief." In other words, you may take pride in widely professing that Obama is an alien, but watch your shame when a behaviorist calls you out on your pretense! My humble suggestion: To stay out of the psych ward, you're better off holding certain beliefs as insincerely as possible.

Anyway, I think it's hilarious how the DSM-IV bluntly excuses false religious beliefs from the definition of "delusion" without the slightest attempt at making epistemic excuses. It is, of course, precisely those false beliefs which are most widespread that are most compatible with ordinary social functioning, and which the medical profession therefore chooses not to involve itself with.

One serious issue is that humans don't estimate numbers well. So when someone says that they think something has a 5% or a 20% chance of being true it isn't clear that they mean that in the sense that you or I would.

Moreover, there may be an issue of how the belief changes over time. If 95% percent of the day there is zero belief in a harmful idea X but in the remaining 5% of the day they are completely certain of X then that's still has potential to be incredibly harmful.

Regarding conspiracy theories held commonly by people. Part of the issue there seems to be general human complacency. A potentially offensive but possibly useful comparison is to people who say that they are absolutely certain that abortion is murder. If they believe that, they should if they are at all moral people go out and spend all their time leading a resistance movement against the terrible genocide going on. Thankfully in this case human moral complacency is acting as a good thing.

There's a related issue which is that sometimes people subscribe to beliefs that they haven't really thought a lot about. This seems for example to be true with a lot of the lower key people who believe that 9/11 was an inside job or who think the Moon landings were hoaxed. They heard something about it a few times that sounded vaguely convincing. But they don't really strongly believe in the ideas.

There's another related issue that you briefly touch upon and that is not seriously discussed enough: The medical definition of delusion is extremely culturally dependent. A a person labeled delusional one year but a decade later have their beliefs count as part of some wider cultural or religious system. Moreover, it isn't a priori clear why such beliefs shouldn't be considered delusional when they are obviously false to any rational individual. The issue here seems to be that as long as they are using a standard form of epistemology (in this case, what peers say is true) then they are more or less functioning like normal humans.

But yet, such beliefs can still be incredibly harmful to both the people possessing the beliefs and to others (examples include HIV-AIDS denial, people who believe that vaccines cause autism, and a variety of the more extreme alt-med beliefs). But simple harmful false beliefs don't seem to be within the purview psychiatry.

I guess the upshot is that these issues are pretty complicated.

I will need to remember the anecdote about the patient and the CIA. Aside from amusement value it does raise some very good points.

Jacob, thank you for pointing me to Caplan's article. I am sympathetic to a lot of Caplan's arguments, such as argument that it does not make much sense for mental illness to be categorized, and that human behavior is better reflected by a spectrum, rather than via cutoffs.

And I agree with you that exempting widespread (if false) beliefs from the diagnostic criteria for delusions is arbitrary, and probably unjustified.

Additionally, as a libertarian, I obviously share many of Caplan's objections and concerns about forced institutionalization.

However, I think that Caplan conflates two issues in his article. One question is whether or not people with severe delusions and hallucinations ought to be labelled within a separate category called "mentally ill." The other is whether or not mentally ill people ought to be hospitalized against their will. Caplan believes that psychiatric disorders are overdiagnosed, and that such categorization perhaps ought not to exist at all. He also argues against forced hospitalization of the mentally ill. However, I don't think that he adequately acknowledges that people are not hospitalized simply for being mentally ill. In fact, people need not have any sort of "diagnosis" to be hospitalized against their will, at least in California. People can only be held involuntarily in the psychiatric unit if they exhibit 1) Significant harm to self (i.e. a suicide attempt or suicidal ideation with a clear plan). Most people who just say "I don't want to live anymore" but don't have a plan or means are discharged. 2) Harm to others (i.e. homicidal ideation with plan) and 3) Inability to care for self (this means that the person cannot self-feed, go to the bathroom by themselves, etc. It does not simply mean that the person will be homeless while mentally ill). People may not like the vagueness of some of these criteria, or even the principle. But it is important to note that, just because someone is deemed as mentally ill, does not mean that he or she can automatically be forcibly held. Again, I do think that forced holds are a matter of concern for people who champion liberty, but it's important to know what situations we're dealing with. I'm not convinced by Caplan's argument that people are not helped by forced holds. I've seen too many people who have voices telling them to kill themselves or others, and who end up thankful to be alive. My main concern, however, is whether or not forced holds are justified, even if they do save lives.

Joshua, I agree with you that one of the flaws in adherence to Bayesian updates, is that we can be very poor at quantifying "how sure" we are. I believe that Tyler Cowen once participated in a bloggingheads with Robin Hanson, in which Cowen expressed his opposition to quantifying beliefs as such. Additionally, I agree that sometimes, until people are actually pressured to clarify their beliefs via certain circumstances, no one can know if they mean what they say. To use your example, if someone says that abortion is murder, we're not really sure if they mean it, until the person is given the option to save two fetuses versus one living human. And, of course, we all are more likely to believe things that are good for our egos. Maybe it's an evolutionary coping strategy that isn't all bad.

About Me

I am a medical student in California. Disclaimer: I take patient privacy very seriously. When I talk about a 22-year-old, 5"5, 125 lb. African-American female with juvenile rheumatoid arthritis, please understand that my real patient might be a 65-year-old, 6"2, 220 lb. Caucasian patient with lung cancer. In other words, I have completely distorted the facts about my patients, and sometimes even completely made up stories. Additionally, I am not a licensed physician, and you should trust your grandma's shaman for medical advice before you trust this blog.